Přehled rekombinantních FVIII

Transcription

1 Přehled rekombinantních FVIII MUDr. Ivan Vonke, OKH, Nemocnice České Budějovice

2 Training Outline Differentiation parameters Pathogen Safety Molecule structure Clinical efficacy Clinical safety Convenience Company reputation/r&d programs Leadership claims

3 PATHOGEN SAFETY Consideration son the risk of transmission of blood-borne pathogens by FVIII therapies

4 Generations within the recombinant FVIII therapy group - based on the addition of animal- and dhuman-derived d blood proteins 3 manufacturing steps for rfviii concentrates FVIII Synthesis in cell culture FVIII Purification FVIII final formulation 1 st generation Recombinate 2 nd generation 3 rd generation therapies produced without the use of human or animal derived additives Kogenate FS, Helixate NexGen, ReFacto ADVATE, (XYNTHA*) * Brand name of ReFacto AF recently licensed in the US by Wyeth

5 Categories within the recombinant FVIII therapy group view of some customers Synthesis in cell culture Purification Formulation 1 st generation Category 2 plasma protein containing 2 nd generation 3 rd generation Category 1 plasma protein free processed Opinion: There is no difference between 2nd and 3rd gen rfviii regarding pathogen safety. 2nd gen products are safe.

6 Categories within the recombinant FVIII therapy group our view Synthesis in cell culture Purification Formulation 1 st generation Category 2 plasma 2 nd generation protein containing 3 rd generation Category 1 plasma protein free processed Opinion: All rfviii are safe with regard to known pathogens. However regarding new emerging hitherto unknown blood-borne pathogens only 3rd gen rfviii products have eliminated the risk of transmission. 3rd generation products are the ADVATE generation

7 References for blood-derived additives in ReFacto The CHO cell line used to produce ReFacto is grown in culture medium that contains human serum albumin;nono albumin is added during purification or in final formulation. Following purification, the albumin concentration is below the detection limit of the assay. Ref.: ReFacto brochure distributed at ASH 2003 Serum albumin is eliminated in the final formulation. The cell culture medium is completely defined and contains only 2 protein components of biological origin: HSA, which is produced by licensed manufacturers for the cell culture process and recombinant insulin. Ref.: Eriksson RK et al (2001) The manufacturing process for B-domain deleted rfviii. Seminars in Hematology 38 (2) Suppl 4:24-31 In 1999 and 2000 three virtually albumin-free formulations (ReFacto, Kogenate Bayer and Helixate NexGen) were introduced. They contain 1000-times less pd albumin than the former formulations Ref.: Zwart-van Rijkom JEF et al. (2002) The uptake of rfviii in the Netherlands. BJ Haematol 119: ReFacto, one of several rfviii products, does contain human albumin. ReFacto is a 3 rd generation product, which also uses human albumin in its manufactutre and is thus a potential source of exposure (potential source of PVB19 transmission) Ref.: Schlesinger KW and Ragni MV (2002) Safety of the new generation rfviii concentrates. Expert opinion drug Safety 1 (3):

8 References for blood-derived additives in Kogenate FS In addition, human plasma protein and traces of host cell proteins and murine IgG, which derive from the fermentation and purification process, are found in the product. Ref.: Kogenate FS European Public Assessment Report For your information: HPPS (Human Plasma Protein Fraction) used in the cell culture medium is not a highly purified albumin concentrate (such as Buminate used for Recombinate) but is an early albumin fraction with relatively undefined plasma contaminants. Kogenate FS, as an advanced rfviii, contains less albumin than Recombinate Ref.: Bayer brochure ASH 2003

9 Summary: Pathogen Safety How do ADVATE and Recombinate compare to competitors? Product Pathogen Safety Baxter ADVATE 3 rd generation rfviii The first and only plasma and albumin free Baxter RECOMBINATE 1 st generation rfviii Human albumin is used as stabilizer and bovine proteins as cell culture medium components Bayer & CSL Behring Kogenate FS Helixate NexGen 2 nd generation Albumin containing plasma fraction in cell culture and albumin detectable in final product Wyeth ReFacto 2 nd generation Albumin in cell culture and in final product VWF containing Pd-FVIII Pd double virus inactivated Main advantage of ADVATE compared to all other FVIII products! All products are safe with regard to known pathogens but only ADVATE is safe with regard to new emerging hitherto unknown blood-borne pathogens. Disadvantage for pdfviii concentrates as having the highest risk of transmission of blood borne pathogens. Newly licensed in the US XYNTHA (=ReFacto AF). 3rd generation B-domain depleted rfviii Q&A available (please contact Paul Woo Global Marketing) Hot Topic Training planned 9

10 FVIII Molecule Structure 10

11 The structure of the B-domain depleted rfviii ReFacto Proteolytic AF (XYNTHA) Cleavage Site Heavy chain High-molecularweight peptide (Amino-Terminal) NH 2 A1 A2 90 kd COOH (Carboxl-Terminal) CU+ Light chain Low-molecular- Weight peptide A3 C1 C2 COOH 80 kd Sandberg H et al (2001) Structural and functional characterization of B-domain deleted recombinant factor VIII. Sem Hematol 38 (2) suppl 4:4-12 and Thromb Haemost (2001) 856:93-100

12 Brochure on the function of the FVIII B-domain by Steven Pipe Summary of findings 12

13 The FVIII B-domain is an important part of an intracellular quality control system for proper FVIII protein folding Immediately after synthesis of the FVIII protein within the CHO cell, cell own chaperons bind to the FVIII b-domain and check whether the FVIII protein is correctly folded. If it is correctly folded this specific FVIII molecule is released into the culture medium. If it is not correctly folded this FVIII molecule is never released but destroyed within the cell. Thus the chaperon b-domain interaction would be needed to guarantee proper folding what is a prerequisite for correct FVIII function. Without a b-domain chaperons cannot interact with FVIII protein, which may cause the release of misfolded d FVIII protein by the CHO cells. Pipe et al (1998) Differential interaction of coagulation factor VIII and factor V with protein chaperones Calnexin and Calreticulin. J Biol Chem 273: Walter S & Buchner J (2002) Molecular chaperones cellular machines for protein folding. Angew Chem Int Ed Engl 41 (7): Zhang X et al (2002) Machinery of protein folding and unfolding. Curr Opin Struct Biol 2:

14 Scheme of proteolytic conversions of FVIII in the course of processing, activation and inactivation (Khrenov et al Blood Coagulation and Fibrinolysis 17(5): ) 388) Step 1 Step 2 A1 A2 B A3 C1 C FIIa 740 A1 A2 B C2 C1 A3 Processing Circulation Step 3 C2 C1 A1 FIIa 372 A2 A3 FVIIIa Activation FIIa and FXa 1689 FXa 1721 Proteolytic Inactivation APC 336 APC 562 FXa 36 FXa 336 Step 4 A1 A2 A1 A2 C2 C1 A3 C2 C1 A3 APC = activated protein C FIIa = activated t factor II = thrombin FXa = activated factor X Cleavage sites are given based on amino acid numbers FVIIIa = activated factor VIII = coenzyme function in Xase complex (FIX/FVIIIa/PL/Ca++) 14

15 Western blot A1-domain inactivation by APC is faster with ReFacto APC 336 APC 562 Mab C5 binding site on A1: C2 C1 A1 A3 A min after addition of APC A1-domain FL-FVIII A1 ReFacto Khrenov AV et al. (2006) Role of the B domain in proteolytic inactivation of activated coagulation factor VIII by activated protein C and activated factor X. Blood Coagulation and Fibrinolysis 17(5): FF 023/HC and Hot Topic # 29 15

16 Western blot A1-domain inactivation by FXa is faster with ReFacto Mab C5 binding site on A1: A1 A2 FXa 36 FXa 336 C2 C1 A min after addition of FXa A1-domain FL-FVIII A1 ReFacto Khrenov AV et al. (2006) Role of the B domain in proteolytic inactivation of activated coagulation factor VIII by activated protein C and activated factor X. Blood Coagulation and Fibrinolysis 17(5): FF 023/HC and Hot Topic # 29 16

17 Summary: FVIII molecule structure How do ADVATE and Recombinate compare to competitors? Product Baxter ADVATE Baxter Recombinate Bayer & CSL Behring Kogenate FS Helixate NexGen Wyeth ReFacto VWF containing Pd-FVIII FVIII structure Full-length rfviii Full-length rfviii Full-length rfviii B-domain depleted rfviii Full-length natural or WT pdfviii Disadvantage for ReFacto: b-domain plays a role in FVIII folding (Pipe) and in FVIII inactivation by APC (Khrenov; FF023/HC; Hot Topic#29). Causing insecurity against b-depleted concept. Functional role of the FVIII B-domain is summarized in Scientific series #6 brochure by S. Pipe Downside: Function of B-domain is scientific discussion; direct link to clinical consequences remains difficult. Advantages for ReFacto: higher rfviii yield; lower price possible; nano filtration possible; Advantages for natural pdfviii; natural glycosylation pattern of the FVIII molecule; better VWF binding capacity? 17

18 CLINICAL EFFICACY Pharmacokinetic 18

19 PK cross over studies of different products gave broad range of FVIII half lifes from hours Half life Study size Data source Recombinate White et al 1997 Hemofil M Recombinate Tarantino et al 2004 ADVATE (pdfviii) Hemofil M (13.1) 13.7 (18) 18 (ReFacto EPAR) ReFacto (14.1) 14.8 (18) 18 Kessler et al 2005 Kogenate Schwartz et al 1990 Koate HS Kogenate (EU) US (14.3) 13.9 (15) 20 Kogenate FS EPAR Kogenate FS (EU)US (14.2) 13.2 (15) 20

20 Recombinate PK study in 1997 demonstrated half life of 14,7 hours in 2002 only 11,2 hours Is todays product less effective? Answer: No Only data from cross-over studies can be compared and show bioeqivalency Different mean half lives reflect variable PK values of different study populations Older studies show tendency to longer half life due to a change in PK calculation methods. (today: removal of extremes) PK results from ADVATE and Recombinate in a cross over study were not significantly different.

21 Comparison of PK parameters can be done only in cross-over studies in the same patient t population due to high h individual id variation. 7-26h 8-18h

22 ADVATE was shown to be bioequivalent to Recombinate in a cross over PK study in n=30 PTPs Parameter RECOMBINATE ADVATE AUC 0-48h* (IU h/dl) 1530 ± ± 436 Adjusted recovery 2.6 ± 0.5 ( ) 2.4 ± 0.5 ( ) Half-life (h) 11.2 ± ± 4.3 Tarantino et al. (2004) Haemophilia 10: 1-10

23 Wyeth claims: ReFacto is bioequivalent to ADVATE Note that a PK study is done in a non bleeding situation. ReFacto and ADVATE may be bioequivalent regarding PK parameters but the pharmacodynamic of the two FVIII molecules (in a bleeding situation) seems to be different (Khrenov see slides 19-22) J. DI PAOLA et al. ReFacto and Advate: a single-dose, randomized, two-period crossover pharmacokinetics study in subjects with haemophilia A. Haemophilia (2007), 13, Khrenov AV et al. (2006) Role of the B domain in proteolytic inactivation of activated coagulation factor VIII by activated protein C and activated factor X. Blood Coagulation and Fibrinolysis 17(5): FF 023/HC and Hot Topic # 29 23

24 CLINICAL EFFICACY % of bleeds solved with 1 infusion Hemostasis ratings (excellent, good, fair, none) based on the speed to stop bleeding and pain relief

25 Comparison of efficacy parameters of rfviii concentrates Product ADVATE 1 81 Recombinate 2 Kogenate 3 Kogenate FS US 4 Kogenate FS EU 4 Kogenate FS Japan 7 ReFacto prophylaxis 5 ReFacto on demand 5 % Bleeds % Bleeds % Bleeds % Bleeds solved with solved with 1 solved with solved with 1 infusion or 2 infusion 3 infusion >4 infusion (82 /73.9) ReFacto 6 PTP study (94) No significant differences between products 1 Tarantino et al White et al Aygören-Pürsün 1997 or Seremetis 1999 or Schwartz Kogenate Bayer EPAR 5 Giangrande Lusher Yoshioka 2001

26 Comparison of efficacy parameters of rfviii concentrates No significant differences between products, slightly increased rate for no response in prophylaxis with ReFacto Product ADVATE 1 Recombinate 2 Kogenate 3 Kogenate FS US 4 Kogenate FS EU 4 Kogenate FS Japan 8 ReFacto (Courter) 5 % Bleeds % Bleeds % Bleeds rated rated good or % Bleeds rated no excellent excellent rated fair response ReFacto (prophylaxis) ReFacto PTP study Tarantino et al White et al Aygören-Pürsün Kogenate Bayer EPAR 5. Courter & Bedrosian Giangrande Lusher Yoshioka (1 case)

27 Warning statement on lack of effect in the ReFacto PI 4.4 Special warnings and special precautions for use Reports of lack of effect, mainly in prophylaxis patients, have been received in the clinical i l trials and in the post-marketing ti setting. The reported lack of effect has been described as bleeding into target joints, bleeding into new joints or a subjective feeling by the patient of new onset bleeding. When switching to ReFacto it is important to individually titrate and monitor each patient's dose in order to ensure an adequate therapeutic response. ReFacto European Public Assessment Report 27

28 Data that have contributed to the ReFacto label change 28

29 Wyeth PV database Dear health care professional letter (September 15, 2003) Time period: April 13, 1999 to April 12, 2003 (4 years update) Patients treated: approximately 5,800 (± 1000) patients used ReFacto in the post-marketing setting AE reports: 85 post-marketing reports of less than desired therapeutic effect and/or low recovery with ReFacto, for which concurrent inhibitor data is negative or not provided have been received from 81 patients ( % 1 of patients) Compared to ADVATE PV: 15 reports after 3566 patients treated (0.4% or 0.14% after exclusion of Brackmann) Events reported bleeding into target joints or into new joints other bleeding or subjective feelings by patients of new onset bleeding low FVIII recovery or bleeding despite the absence of inhibitors increased bruising or sensation of bleeding into target joints required higher than anticipated doses for bleed resolution. increased bleeding after switching therapy to ReFacto. Reporting rates determined on the basis of spontaneously reported post-marketing adverse events are generally presumed to underestimate the risks associated with drug treatments. 29

30 Case report on inadequate clinical efficacy of prophylaxis in a severe hemophilia A subject with no inhibitor receiving ReFacto Patient: 28-year-old male with severe hemophilia A switched from Recombinate to ReFacto for prophylaxis Result: despite administered ReFacto every 48h, daily injections of 28 IU/kg were necessary to treat 3 new hemarthroses rfviii recovery was 1.68 %/IU/kg and half life just 6h Patient wanted to be switched back to Recombinate Prophylactic treatment every 48h cleared up joint bleedings in 10 days rfviii recovery was 2%/IU/kg and half life was 12 hours Peynet J et al (2002) Clinical and Biological Failure of Prophylactic Treatment with B-Domain Deleted Recombinant FVIII in a Severe Haemophilia A Patient without Inhibitor. Presented at Deauville Maladies hemorragiques gq hemostase au feminin; May 2002 and abstract presented at the 44th Annual congress of the American Society of Hematology 2002, published in Blood 100 (11) (abstract nr.:3904) 30

31 After lack of bleeding prevention of ReFacto lower FVIII activity recovery was found - independently of assay used FVIII:C recovery of Refacto vs. Hemofil M Patient 1 (43 y.o. male) FVIII:C recovery of Refacto vs. Recombinate Patient 2 (19 y.o. male) % of expected FVIII activity before treatment 1h 3h Hemofil Refacto d FVIII activity % of ex pecte before treatment 1h 3h Recombinate Refacto ty % of expec cted FVIII activit FVIII:C recovery of Refacto vs. Recombinate Patient 3 (21 y.o. male) before treatment 1h 3h Refacto ected FVIII activ vity Recombinate 40 % of exp 20 0 FVIII:C recovery of Refacto vs. Recombinate Patient 4 (19 y.o. male) before treatment 1h 3h Recombinate Refacto Hanna & Zimmerman (2001) Lack of Adequate Bleed Prevention and FVIII Activity Recovery with Refacto: A Series of Case Studies in Hemophilia A Patients. Blood 98 (Suppl 1): 531a,

32 Summary: Clinical Efficacy How do ADVATE and Recombinate compare to competitors? Product Clinical Efficacy Baxter ADVATE 93% bleeds resolved with 1-2 infusions Half live: 9.7 +/-1.9 (children) /- 3.1 (adults) Baxter Recombinate 91% rated excellent or good (PTPs) Half live: /-4.9 (adults) Bayer & CSL Behring Kogenate FS Helixate NexGen 95% bleeds resolved with 1-2 infusions Half live: /-1.56 CI licensed Wyeth ReFacto 93% bleeds resolved with 1-3 infusions Half live: 14.8+/- 5.6 Warning statement Lack of effect in prophylaxis VWF containing Pd-FVIII Half live: h Disadvantage for ReFacto due to B-depletion Lack of effect in prophylaxis (PI warning statement); Wyeth s rebuttal: Development of ReFacto specific concentrate standard to overcome FVIII assay issues (Hot Topic#16) Increase of FVIII in each vial by 20% (Hot Topic#16) PK cross-over study demonstrated bioequivalency with Hemofil M and ADVATE (Hot Topic#16) Advantage for Kogenate and Helixate: licensure of continuous infusion is this a real advantage? 32

33 CLINICAL SAFETY Inhibitors in PUPs 33

34 Brochure on the development of inhibitors following FVIII replacement therapy what do we know? By Brigit it Reipert Development of Inhibitors following FVIII Replacement therapy What do we know? By Birgit Reipert, PhD Scientific Series No. 7 Fast Fact 035/HC Can be ordered via the GCMA website: /NewBrochure/ListBook.asp?GroupID=50 Scientific Series No. 7 BAXTER 34

35 Kogenate FS showed low inhibitor rate in PUPs (15%) Reasons why KOGENATE FS is not safer than ADVATE and RECOMBINATE PUPs are not a suitable population p to study product-related immunogenicity (EMEA clinical guidelines) Due to significant variations in study design PUP studies cannot be directly compared The Kogenate FS PUP study included less PUPs with African origin, a patient group with a well-known increased inhibitor risk More PUPs in the Kogenate FS study (70%) were set on prophylaxis, a treatment-related factor known to reduce inhibitor risk. Interestingly all inhibitors occured in the on demand group. The Kogenate FS study monitored only the first 20 FVIII exposure days. Inhibitors that developed after that were not counted. For more details please refer to brochure Scientific Series # 7 (by B. Reipert) 35

36 Percentage of PUPs on prophylaxis are different in various PUP studies The most recent PUP study had a larger number of patients who switched to prophylaxis during study Kogenate FS Kogenate Recombinate Study Period No. (%) of prophy. patient at study end 43 (70%) N/A 23 (32%)* No. (%) of inhibitor patientsonanon an 9 (100%) N/A 20 (91%) demand regimen * 6/73 (8%) switched prior to 20 EDs; 19/73 (26%) switched prior to 50 EDs Kreuz et al (2005) Thromb Haemost 93: ; Lusher JM et al (1993) n Engl J Med 328: ; Bray GL et al(1994) Blood 83 (9):

37 Differences in Study Observation Period Patients are generally at highest risk for inhibitor development within the first 50 EDs; most, but not all, develop within the first 20 EDs Kogenate FS Kogenate Recombinate Observation Period 2 years or 20 EDs 5 years or 100 EDs 5 years or 100 EDs EDs prior to inhibitor development: range (3-18) (3-54) (3 69) No. (%) of patients w/out 20 EDs 8 (13%) N/A 3 (4%) Kreuz et al (2005) Thromb Haemost 93: ; Lusher JM et al (1993) n Engl J Med 328: ; Bray GL et al(1994) Blood 83 (9):

38 Differences in Study Populations: Ethnicity Blacks and Hispanics are at highest risk for inhibitor development Kogenate FS Kogenate Recombinate No. (%) of blacks and hispanics 5 (8%) 14 (22%) 19 (26%) No. (%) of blacks and hispanics w/ inhibitors 2 (40%) 6 (43%) 8 (42%) Kreuz et al (2005) Thromb Haemost 93: ; Lusher JM et al (1993) n Engl J Med 328: ; Bray GL et al(1994) Blood 83 (9):

39 CLINICAL SAFETY Inhibitors in PTPs 39

40 ReFacto compared to ADVATE and Kogenate/Helixate PIs ReFacto The risk of developing inhibitors is correlated to the exposure to antihaemophilic factor VIII, this risk being highest within the first 20 exposure days. In the postmarketing setting, high and low titre inhibitors have been observed in previously treated patients. Cases of recurrence of inhibitors (low titre) have been observed after switching from one recombinant factor VIII product to another in previously treated patients with more than 100 exposure days who have a history of inhibitor development. Patients treated with recombinant coagulation factor VIII should be carefully monitored for the development of inhibitors by appropriate clinical observations and laboratory tests Also there have been spontaneous postmarketing ti reports of high h titre inhibitors involving i previously treated patients. ADVATE, Kogenate Bayer, and Helixate NexGen Rarely, inhibitors may develop after the first 100 exposure days. Cases of recurrence of inhibitors (low titre) have been observed after switching from one recombinant Factor VIII product to another in previously treated patients with more than 100 exposure days who have a history of inhibitor development. Patients treated with recombinant coagulation Factor VIII should be carefully monitored for the development of inhibitors by appropriate clinical observations and laboratory tests. European Public Assessment Reports on the EMEA website: europa.eu/humandocs/humans/epar/advate/advate.htm As of February 27,

41 Data that have contributed to the ReFacto label change 41

42 Case report on inhibitor developments after ReFacto Factor VIII inhibitor detected in 4 hemophilic subjects on ReFacto Patients: 3 PTPs aged 27, 33 and 66 with severe hemophilia A 1 PTP aged 46 with mild hemophilia A Inhibitor was detected t d 28, 19, 63 and 14 days after exposure to ReFacto Inhibitor titers were 0.9 BU, 5.3 BU, 40 BU and 1.8 BU For 2 patients bypassing agents were needed the other 2 were treated with elevated ReFacto doses. Roussel-Robert V et al (2003) Factor VIII inhibitors development following introduction of B-domaindeleted recombinant factors VIII in four hemophilia A previously treated patients. Presented at Deauville Maladies hemorragiques hemostase au feminin, May 2002; published in J Thromb Haemost 1: 11,

43 Summary: Clinical Safety How do ADVATE and Recombinate compare to competitors? Product Baxter ADVATE Baxter Recombinate Bayer & CSL Behring Kogenate FS Helixate NexGen Wyeth ReFacto VWF containing Pd-FVIII Clinical Safety (Inhibitors) PTPs: 1/145 (0.7%) PUPs: 5/25 (20%) PTPs: 0/69 (0%) PUPs: 22/73 (30%) PTPs: 1 recurrent/71 PUPs: 9/60 (15%) PTPs: 1/113 (0.9%) PUPs: 32/101 (32%) Warning statement EMEA workshop outcome PTPs: most 0 PUPs: 4-26% Discussion Disadvantage for ReFacto: High titer inhibitors in PTPs (warning statement and EMEA workshop data) Claimed advantage for Kogenate and Helixate: Bayer claims for Kogenate the lowest inhibitor rate (15%) in PUPs from all rfviii concentrates. Claimed advantage for pd VWF containing FVIII concentrates: Pd VWF-containing FVIII have been discussed as less immunogenic in PUPs (Goudemand (FF022/HC and FF025/HC) and Chalmers (FF029/HC) versus CANAL study; (FF026HC and FF028HC; Hot Topic#31) ) and more successful in ITI. Our view on inhibitor development is summarized in Scientific Series #7 and Fast Fact 035/HC 43

44 CONVENIENCE 44

45 Summary: Convenience How do ADVATE and Recombinate compare to competitors? Product Convenience Infusion volume Potency range RT storage Reconstitution devices Baxter ADVATE 5 ml IU 1 24 m / 2 m RT BaxJect II Baxter Recombinate 10 ml IU 24 m / m RT BaxJect II Bayer & CSL Behring Kogenate FS Helixate NexGen 2.5 ml/5ml IU 30m / 3 m RT Bioset/Mix2vial Wyeth ReFacto 4 ml IU 24m / 3 m RT Pre-filled syringe VWF containing Pd-FVIII 5-10ml IU 0 to 3 years RT (Fanhdi/Grifols) Needle systems Preferred infusion volume is customer specific (Nordic versus US) What is better? 5 ml is best balance between infusion rate/time and loss of product. ADVATE and Recombinate have the fastest infusion time (10ml/minute) Wide potency range ( IU) is seen as advantage increase of flexibility; reduction of infusion time RT the longer the better - increase of flexibility (travel) Preference for devices customer specific different surveys give different results. Prefilled syringes are made of glass (disadvantage). But Baxter s BaxJect II is preferred by many patients and nurses (market survey) IU and 3000 IU approved in the US, expected for Europe May

46 ADVATE future improvements (Europe) 2000 and 3000 IU potencies 6 months RT CI indication (15 prospective patients) ITI indication Reconstitution devices All in one syringe: Lyoject for those who use only one vial was good PressMix device (pre-assembled BaxJect II) one shot was overwhelmingly preferred Submission Approval Q2/2008 Q4/2008 Q4/2008 Q2/2009 Q2/2009 Q4/2009 expected Q1/2010 2ml diluent choice for pediatric use expected

47 COMPANY REPUTATION 47

48 Definition of leadership based on a survey Leadership is....to have a vision for the future hemophilia treatment (research, innovation)..to develop product improvements (longer half life etc)..to show responsibility for pricing policy (social responsibility)..to be a reliable company (research study data)..to provide continuous funding of research studies, patient and physicians education and support (committment to the community, service) 48

49 BAXTER 49

50 Reputation as an innovator Baxter has a tradition in developing advanced FVIII treatment with firsts in each product category 1) Hemofil M (pdfviii) (first mab purified, first SD treated t pdfviii) 2) Recombinate (first rfviii) (also claimed by Wyeth as Recombinate was developed by Genetic Institutes, which today is part of Wyeth) 3) ADVATE (first plasma & albumin free rfviii) Wyeth had the first plasma/albumin free rfix (BeneFIX) 50

51 Baxter s R&D pipeline 1) rvwf for the treatment of VWD (by-product of the ADVATE production) PK study in humans to be started in ) rfviii with improved PK properties (4 programs: pegylated rfviii, pegylated rvwf, rfviii or rvwf with different glycosylation) Clinical studies to be started 2008 probably with >1 product 3) Mimetic proteins Low MW peptides that are able to mimic FVIII function in clotting cascade (Partner Jerini AG, Germany) 4) radamts 13 for treatment of TTP (thrombotic thrombocytopenic purpurea) = super orphan drug status We currently look into potential additional indications Presented at Study Update Meetings in Portugal, at WFH 2006 and ISTH 2007 Latest update at HRSU in Rome (April 2008) 51

52 BAYER 52

53 Bayer s R&D pipeline as disclosed at GTH ) Projects for FVIII with prolonged half-life Goal: effective prophylaxis with significantly reduced FVIII application Clearance receptor binding mutations (principle: weaker binding to receptors results in slower clearance) LRP, HSPG Activity mutations of FVIII S-S bridge between A2 and A3 domains slows down deactivation of FVIII (Radtke Thromb Haemost 5:102) Site specific pegylation (steric hindrance of ligand binding); PK in mice and rabbits showed 2-fold increase of half-life Unspecific pegylation (PegLip Kogenate FS = BAY ) partnering with Recoly) 2) Gene therapy (partnering with AskBios) FIX Biological nano particles (BNP, capside chimers) Projects to increase efficiency of gene transfer Presented by Dr. Lemm (Bayer Berkely) at GTH

54 Studies published for KOGENATE FS PegLIP Powell JS et al. Safety and pharmacokinetics of a recombinant factor VIII with pegylated liposomes in severe hemophilia A. Pre-published on-line: doi: /j x ; accepted for J Thromb Haemost Fast Fact 033/HC Spira J, Plyushch OP, Andreeva TA, Andreev Y. Prolonged bleeding-free period following prophylactic infusion of recombinant factor VIII (Kogenate FS) reconstituted with pegylated liposomes. Blood 108 (12): ; 2006; Fast Fact 001/KC&BY 54

55 Downsides of the PEGLip Kogenate FS: pathogen safety level and long term tolerability PEGLip Kogenate FS still based on a 2 nd generation rfviii = not plasma/albumin free The mechanism of action (MoA) for the clinical effect (prolonged bleed free time after prophylactic dose) observed in the study is unknown. PK parameters (recovery and half-life not improved in humans) There was a statistically significant increase in LDL cholesterol levels following the 2 nd infusion of Kog-FS PEGLip. This raises an important safety question regarding what the cumulative effect of a 1X week prophylaxis regimen of Kog- FS PEGLip would be when used over an extended period of time. Infusion via pumps over minutes not very convenient Patient population not comparable with W-EU standards. One inclusion criterion for patients in this study was at least 4 bleeds/months which corresponds to 48 bleeds per year. Patients with this high bleeding frequency are not available in developed countries in Western Europe. This shows that patients are obviously extremely undertreated when they started the study. Therefore any treatment should reduce the number of bleeds and thereby prolonging the bleed free period. 55

56 Details on BAY 80 comparison study Planned: 250 patients from 63 centers in 14 countries Study arm 1: 35 IU/kg BAY 80 once a week Study arm 2: 25 IU/kg Kogenate FS 3 times a week Bleeds are treated with BAY 80 or Kogenate FS respectively Randomized and double blind Challenges: milky (BAY 80) versus clear (Kogenate FS) solution 35 versus 25 IU/kg 1x versus 3 infusions i per week Solution: Use Kogenate FS in liposomes without PEG (milky) Use liposome buffer without FVIII as mock infusions 2 times a week 56

57 Bayer also focused on demonstration of their leadership in hemophilia Bayer hemophilia Award program (launched in 2002) The Bayer Hemophilia Awards Program supports basic and clinical research and education in hemophilia. Through grants provided to early career investigators, fellows in training, and other hemophilia care professionals, the program seeks to support the next steps for the next generation of care and treatment options for people with hemophilia worldwide. Spending: $2.7 mil per year for Special project awards Early career investigator awared Clinical training award Hemophilia caregivers edication award 57

58 WYETH 58

59 Number of inhibitors in the ReFacto AF PTP study did not meet tfda requirements and was discontinued d In 2003 the FDA set as an upper limit for inhibitor formation of < 6.8% which translates into maximal 1 inhibitor in n=80 study subjects. ReFacto AF Pivotal Trial (Protocol 306) was considered a failed trial by the FDA for exceeding the proscribed safety criterion. The ReFacto AF trial demonstrated 3 inhibitor cases in ~90 patients. (BASS XII, Savannah, Georgia, Nov 8-11, 2005; annual Biopharmaceutical applied statistics symposium; Presentation by David Huang (Wyeth) Wyeth triggered discussions about patient- and product-related inhibitor risk factors and proposed a different methodology for the assessment of inhibitor development in PTP studies (current method: confidence interval approach; proposed method: Bayesian approach). Main argument: with the CI approach currently licensed and safe products such as Recombinate and Kogenate FS would not meet safety requirements. With Bayesian approach all licensed products would meet requirements. 59

60 Wyeth s latest development: XYNTHA Study name: ReFacto AF (albumin free) Brand name in the US: XYNTHA (licensed in Feb 2008) Is a plasma/albumin free 3rd generation rfviii product similar to ADVATE B-chain depleted rfviii produced in CHO cells without addition of human or animal-derived proteins and without the use of mouse mab (ligand technology); stabilized by sucrose. Addition of a nanofiltration step(only suitable for b-depleted FVIII molecules) Global Q&A available (please contact Paul Woo from Global Marketing); Hot Topic Training planned 60

61 ReFacto FS = XYNTHA..from the Q&A Comment: Please do not use the brand name XYNTHA in order not to help Wyeth diverting from the safety and efficacy issues experienced with ReFacto. ReFacto AF might be the brand name in EU 61

62 Wyeth s R&D pipeline pp as disclosed in press releases Cooperation with France s Nautilus for a longer half life FIX (by changes in aa sequence in order to slow down breakdown of protein and improve duration of the drug (The Associated Press ; February 5, 2007) Wyeth World s 4 th largest biopharmaceutical company builds on committment to innovation in hemophilia (DrugNewswire; Feb. 5, 2007) Wyeth sign research agreement with MediVas LLC (San Diego, Ca) to develop haemophilia treatments (AFX News; Feb. 5, 2007) MediVas: unique polymer-based drug delivery system to develop advanced delivery methods (non IV) for rec. Hemophilia products and improve patient convenience through the creation of a longer half-life for these proteins (Earthtimes.org; Feb. 5, 2007) Not much details published yet 62

63 OCTAPHARMA 63

64 Press release from October 17, t h / t /01 t h /01 t h Octapharma s R&D offers exciting new therapeutic approach to management of haemophilia OCTAGENE GmbH Biomedical Laboratories (OCTAGENE GmbH) is a privately owned biotechnology company specializing in the development of new treatments against haemophilia. It was founded in 1997 by Dr. Charlotte Hauser as a joint venture with Octapharma. Dr. Hauser, the managing director of OCTAGENE GmbH has long experience in the research of recombinant proteins and gene therapy. The strategic alliance provides OCTAGENE with state-of-the-art technologies and enables an international exchange of know-how how. The company is located in Martinsried near Munich, Germany, a place that has already acquired a world-wide reputation as a leading biotechnology research centre. OCTAGENE GmbH is a product-oriented R&D company whose main focus is the production of novel recombinant clotting factors and gene therapy in order to discover alternatives to the customary substitution therapy. Recombinant clotting factors are manufactured biosynthetically. This eliminates any risk of viral contamination. OCTAGENE is focusing on the improvement of recombinant clotting factors with respect to human compatibility. Unlike all other recombinant clotting factors that are based on rodent cell lines OCTAGENE s recombinant factor VIII has been developed on the basis of a human cell line. Preliminary studies in animals have demonstrated that this product (Octagene SF ) displays stability and clearance kinetics comparable to those of a licensed recombinant FVIII, indicating that the protein is physiologically active in vivo and providing strong support for its therapeutic potential in humans.. It is anticipated that OCTAGENE SF will begin clinical development within the next one or two years. In parallel, OCTAGENE is pursuing an alternative strategy: gene therapy as a completely new form of treatment. OCTAGENE s concept is based on the fact that specific hormones which are given orally can penetrate the cell membrane. The hormone binds onto a hormone receptor which in turn is coupled with the DNA that defines the genetic blueprint for the production of the clotting factor in the cell. Oral application of gene therapy offers enormous benefits to patients, not least of which will be the avoidance of repeated painful, time-consuming infusions. 64

65 Latest information on Octapharma s rfviii project (Source: presentation at GTH 2008) H. Sandberg (Stockholm): A novel rfviii expressed in a human cell line The rational to have rfviii produced in human cells is that the glycosylation pattern of the protein would be more natural and this could improve the function. rfviii produced in hamster cell lines are known to differ slightly in their glycosylation from human FVIII. Details on the new rfviii: B-domain depleted Expressed in the human embryotic kidney cell line HEK 293 F that was established 10 years ago and is also used for production of activated protein C (XIGRIS by Ely Lilly). Cell culture medium free of animal-sourced material No animal-sourced protein used what about human albumin? Purification via 5 chromatography steps (IA, IE, size exclusion) 2 virus inactivation steps (SD, nanofiltration) Specific activity: 10,000 IU/mg protein rfviii is fully sialyated and does not express Neu5Gc such as the hamster cell produced rfviii ( more natural gylcosylation pattern ). New rfviii has a higher affinity to VWF whereas PL binding, thrombin generation, 1-stage and chromogenic assays s are comparable with other rfviii. This was discussed as a potential disadvantage that can cause a reduced efficacy. Pre-clinical studies have demonstrated no toxicity of the new rfviii (acute tox in rats, local tolerance in rabbits, repeat dose tox studies in cynomolgus monkeys) Infusion of the new rfviii into hemophilic dogs resulted in normal FVIII recovery and half life. Product developed in cooperation with Octagene Munich, Octapharma Stockholm, Sweden and David Lillicrap, Kingston, Canada. 65

66 Some speculation why Octapharma went for a b-domain depleted rfviii after all these safety and efficacy issues known for ReFacto rfviii yield was too low in human cell line. Using a B-depleted FVIII concept is known to increase rfviii release by cells. Production in human cells requires better virus inactivation or removal. The B-depleted FVIII molecule can be nano filtrated. 66

67 CSL-Behring is working on a rfviia-albumin fusion product with prolonged half life (Source: Dr. Schulte head of R&D at Behring (Marburg, Germany at GTH 2008) New approach to prolong half life of complex coagulation factors: fusion of human albumin with other proteins to prolong their circulation half lives. Rationale for the albumin fusion concept Albumin has a circulation half life of 20 days Albumin is the main protein in plasma (42g/l) The molecule structure of albumin is known Albumin-cytokine fusions have worked already Results rfviia and albumin fusion is done on DNA level. The fusion protein is then produced in CHO cells PK studies in rats have demonstrated a 6-fold prolonged half life and a 2-fold increased recovery Half life in rats In vivo recovery in rats Albumin 620 min 106% rfviia (NovoSeven) min 20-35% ralbumin-rfviia fusion protein 262 min 47% Fusion protein has somewhat (70-90%) reduced activity which can be optimized by the length of the linker between albumin and rfviia. BT could be normalized in a ROTEM system when the fusion protein was added to a human inhibitor plasma. The reduced activity was automatically solved by the increased recovery. Challenges by the audience Is it possible that the linker between albumin and FVIIa is immunogenic? Could the system also work with FVIII and would an albumin-fviii fusion be able to bind VWF? 67

68 Summary: Company reputation How does Baxter compare to competitors? Product Baxter Bayer CSL Behring Wyeth Plasma supplier Company Image (leadership) Large R&D program presented: pegylated ADVATE (longer half life product) rvwf Mimetics (non IV) Large R&D program presented: Next gen Kogenate pegylated liposomes (longer half life) already in clinical studies FVIII mutations (of clearance receptors to slow down clearance) site-specific ifi pegylation Genetherapy (FIX) R&D project presented at GTH 2008 in Germany: rfviia/albumin fusion with 6x longer half life in rats Leader in VWD XYNTHA (3 rd gen rfviii licensed in the US) Cooperation with Nautilus (longer lasting mutant of rfix; longer half-life and non IV projects) B-domain depleted rfviii (Octapharma) From a human cell line (HEK 293F embryotic kidney cell) Claim: natural glycosylation l and better VWF binding affinity ; Preclinical studies in dogs done. (GTH presentation 2008) Disadvantage in leadership for plasma suppliers due to lack of latest rec. technology? However Octapharma is working on a B-depleted rfviii produced by human cells Baxter and Bayer started to disclose R&D programs very early before product enters clinical studies Question is how project failures are rated by customers? Potential advantage for Wyeth: only company with rfviii and rfix in their portfolio (could also be a disadvantage due to a fair share policy) 68

69 COMPANY CLAIMS 69

70 Reputation as innovators in hemophilia therapy 1) Baxter developed Hemofil M, the first mab purified SD treated pdfviii 2) Baxter and Wyeth claim to have been the first with rfviii (Recombinate) (Fact is that Recombinate was developed by Genetic Institutes, which today is part of Wyeth, Baxter was the first who marketed Recombinate) 3) Bayer and Wyeth claim to have been the first with an albumin free formulated rfviii (Kogenate FS and ReFacto) 4) Wyeth claims to be first with a b-domain depleted rfviii, the concept of the future (because gene therapy projects all with b-depleted rfviii). 5) Baxter had the first plasma/albumin free rfviii (ADVATE) 6) Wyeth had the first plasma/albumin free rfix (BeneFIX) 7) Bayer had the first rfviii with longer half life in clinical studies.. 70

71 Company claims Baxter Bayer CSL Behring Wyeth Octapharma Company Image (leadership) Leader in Hemophilia Leader in Hemophilia and in Hemostasiology Leader in VWD (Humate/Hemate) Leader in rec. technology and only company with full portfolio (rfviii and rfix) Partner in plasma fractionation Leader in VWD (Wilate) and in ITI General considerations All companies do claim leadership by presenting innovative products from their R&D pipeline Lack of the latest recombinant technology is seen as a disadvantage in leadership. That is why Octapharma and CSL Behring also started to present their recombinant products to come (B-depleted rfviii produced by human cells and a rfviia with longer half life). The disclosure of new products before clinical i l study results are available bears two risk factors: a) how will customers rate project failures? and b) competitors can be motivated to start similar projects. The advantage to have a full recombinant hemophilia portfolio (rfviii and rfix like Wyeth) can also be a disadvantage when fair share policy plays a role Being a leader may not everywhere be perceived as a positive trait. Being a partner may be the higher valued feature. 71